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Chirurgical Transactions, on the Development of Torulæ in theUrine. When sugar is present in urine in smaller quantitiesthan can be detected by the action of chemical re-agents, hehas shown that the sporules of the sugar fungus, or even ahigher stage of development, may be readily detected by themicroscope.January 1854.

CASE OF ANEURISM OF EXTERNAL ILIACCURED BY GALVANO-PUNCTURE.

By E. U. EYRE, ESQ., Surgeon H.E.I. Co.’s Service.(Continued from p. 95, vol. ii. 1553.)

MR. FERGUSSON presents his compliments to the Editor ofTHE LANCET, and, in handing the enclosed, begs to expresshis conviction that it will be read with great interest, as acontinuation of that part of the case already published somemonths ago (summer, 1853). Mr. Fergusson therefore hopesthat it will also be inserted in an early number of the journal.

George-street, Hanover-square, Jan. 24th, 1854.

Sergeant H- recovered perfectly as regarded the localdisease, but some months after, he became dropsical, andsuspicions were entertained, from some symptoms present,that he laboured under aneurism of the aorta. He was not atthe time under my care, but from his medical attendant Ilearned these particulars, and on his death I was favoured withthe following post-mortem report, which I give in abstract :-Heart much enlarged, weighing thirty ounces; valves

normal. "On a section being made in the course of theexternal iliac artery of left side, an aneurismal tumour, of thedimensions of a hen’s egg, was discovered in the margin ofthe base of Scarpa’s triangle, being immediately beneathPoupart’s ligaments of that side, and where the external iliacbecomes the femoral artery. On incision, the sac of theaneurism was totally blocked up by fibrinous deposit, thusobliterating the calibre of the vessel. The coats of the arterywere considerably thickened. No aneurism was to be seenthroughout the whole course of the circulation."The treatment of aneurism by galvanism may be more

common than I supposed when I drew up the case. I have,indeed, met with a few since, in periodicals.

Bellary. Dec. 1853

THE EFFICIENCY OF THE SULPHURIC ACIDIN DIARRHŒA.

BY GOODEVE BOWRA, ESQ. M.R.C.S.E.As much has been said and written lately on the treatment

of diarrhw-a, I beg to offer my testimony on the happy effectsof sulphuric acid on persons of all ages, with the full convictionthat it is the quickest and most palatable, consequently thebest remedy for that disease.

I was requested two years ago to send medicine to a younglady subject to diarrhoea, who had taken a passage to Chinain a ship not carrying a surgeon. Thinking there must besome mistake, I went on board the vessel and saw the chiefofficer, who thought himself quite competent to treat (frombooks and a medicine chest) any disorder likely to arise on thevoyage. On asking this gentleman what he would do in casesof diarrhoea, his off-hand reply was, "Never care for that;always carry plenty of sulphuric acid on board and I havenever known it fail."On the same evening I was called to a lady, seventy-five

years of age, very subject to these attacks, which always lasteda week or more, and as it was of great consequence she shouldreturn into the country in two days, I made up my mind totry the sulphuric acid, believing I should not be more successfulwith the old chalk mixture than her medical friend at home.The following morning I found her up, and so much better,

that she had only taken two doses, I gave her a third, whichcompletely cured her. Since then I have used nothing else(save a mustard poultice) in all cases, either with or withoutpain, both in private practice, and at an institution to which Iwas attached, and I confidently state that during the wholeperiod I have used it I have not met with one unsuccessfulcase. The only difficulty is, to persuade some people thatacids would not increase their disorder, particularly thoseaccustomed to the old chalk and aromatic confection treatment.

I now constantly recommend patients subject to diarrhoea,or who are nervous about cholera, to keep a bottle of the

sulphuric acid mixture in the house, and on the first symptomof their complaint instantly to take a dose, which is generallysufficient to effect a cure. Aliny of these patients (I fear,jokingly) tell me they shall expect double charges, as two orthree drafts of the acid mixture have more effect than the samenumber of bottles of the chalk mixture; and I may add, I feelso satisfied with the success of a two years’ trial, that I haveno hesitation in asserting it is my full belief, that deaths fromcholera and diarrhœa would be very materially diminished ifthe authorities would appoint an agent in all poor neighbour-hoods, to give a dose of the sulphuric acid mixture to everynecessitous applicant suffering from bowel complaint. Theywould have plenty of persons desirous of availing themselvesof this remedy, if I may judge from the gallons I gave awaylast summer.Charterhouse-square, 1854.

P.S.-It may be as well to state that the cost of the aboveremedy is one shilling a gallon, or thirteen doses a penny. Ifadministered as on board the vessel to which I have referred-that is to say, without any colouring matter, the six gallons ofmixture will cost one penny, so that the expense to be incurredby the government in relieving the suffering poor would be buttrivial.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumet dissectionum historias, tam aliorum proprias, collectas habere et interse comparare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proœmium.

CONSERVATIVE SURGERY AND ITS RESULTS.

1. ST. MARY’S.....

2. ROYAL FREE ........

3. ST. BARTHOLOMEW’S 4. UNIVERSITY COLL.. i

" "

5. KING’S COLLEGE....

6. ST. THOMAS’S........ ’ ^

’’ " ’

7. LONDON ...............

. 8. KING’S COLLEGE....

’ Cases of removal of) carious bone from

the foot; favour- i able 1’esilltsin some

instances and fail-ure in others. Cases of flap am- putation of the

thigh, leg, arm, and forearm; veryefficient stumps.Excision of the headExcision of the head of the femur.Excision of the head of the femur.

Excision of the wrist-joint.Removal of theRemoval of thewhole of the carpusin two cases.Removal of the whole carpus.

(Modification ofSyme’s operationat the ankle-joint;non-excision of theastragalus.

Amputation at theankle-joint.Amputation at the

ankle-joint.

II

Mr. COULSON.

IMr. T. WAKLEY.

Mr. STANLEY.Mr. ERICHSEN.} 11

Mr. FERGUSSON.

Mr. SIMON.

.,

Mr. CRITCHETT.

Mr. FERGUSSON.KING’S COLLEGE HOSPITAL,

Excision of the Wrist-joint.(Performed by Mr. FERGUSSON.)

WE, this day, continue the series of cases on excision.of joints, which we have been enabled, by the courtesy ofthe medical officers, to collect in different hospitals of thismetropolis, and in proceeding according to the above list nTecome to consider the resections of the wrist-joint which hr.vebeen performed by Mr. Fergusson. It would be needless to

repeat here what we said in the preceding "Mirror" respect -

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ing this operation: the latter may be considered in its infancy;its weak points are very conspicuous, and no redeemingfeatures have as yet, probably from want of time, been

brought forward. One, however, of the latter, we mightperhaps mention at this early period—viz., that but very littleharm can accrue from endeavours to save the hand, since thearm may in case of failure be taken off above the wrist with-out subjecting the patient to any further risk than if theamputation had taken place at first, though the loss of time,the casualties which may attend any surgical operation, pro-tracted suppuration, and the possible continuation of pain formonths, should carefully be weighed against the chance ofpreserving a hand which may not turn out very useful. Thisoperation may in fact be looked upon in the same light as theinjections of perchloride of iron into aneurismal sacs, nævi, andvaricose veins. The utility and the harmlessness of theseinjections are very much doubted by some French surgeons ofeminence, among ivhom Malgaigne may be mentioned; whilstthe fatal results and accidents of various kinds, which havefollowed these injections, are looked upon without dread, byother equally distinguished men, among whom Velpeau is pro-minent. The latter surgeon is of opinion that the trialsshould be continued with all the necessary prudence andcaution, as no progress whatever could be made in surgery ifwe were to be disheartened by the reverses which frequentlyaccompany the adoption of new operations, or novel methodsof treatment. It is very likely, from the tone of the discus-sion, that carefully conducted trials as to the efficacy of theinjections of the perchloride of iron will continue to be made;the same may perhaps not be said respecting excision of thewrist, but it is plain that the question will hardly ever besatisfactorily solved, except a sufficient number of facts comebefore the profession. We beg to adduce two of theserespecting patients upon whom Mr. Fergusson performedexcision of the wrist-joint.

George G-, aged twenty-two years, a cabinet-maker,.and native of Gainsborough, was admitted into the Londonward July 23, 1851. He stated that, twelve months beforeadmission, while planing a piece of wood, he strained hiswrist, but paid no attention to the accident at the time.About three months after this, the part began to give himmuch pain; he nevertheless followed his occupation, but Iwas at last obliged to repair to Hull, where he applied to asurgeon, who told him that one of the bones of the wrist wasdisplaced. This medical officer tried to reduce the dislocation,ordered a blister to be raised on the part, and subsequentlyused cauterization. At last matter formed, which was givenexit to by incision. The patient seems now to have beensubjected to repeated cauterizing with sulphate of copper,and getting no better, he applied to another surgeon at Man-chester, who stated that no displacement had ever occurred.Applications of various kinds were now used for three weeks,but to no purpose. A third surgeon was subsequently con-sulted, and an incision was again made which gave vent to agreat deal of matter. Poultices of cow-dung were now advisedby officious friends, but the discharge became then so abundantthat the patient was obliged to discontinue the application.The poor man now presented himself to Mr. Fergusson,

when the wrist had the following appearance :-The swellingextends from two inches above the joint to the centre of themetacarpal bones; there is a large and irregular sore on thepalmar surface of the wrist; on the dorsuni of the hand a largeulcerated opening at the base of the metacarpal bone of thethumb, and another at the centre of the metacarpal bone of theindex finger. The joint is considerably deformed; there ismuch purulent discharge, and every movement which is im-parted to the articulation gives excessive pain.On admission, the hand was placed on a well-padded splint,

presenting a depression at the wrist to allow of a poulticebeing applied between the splint and palmar surface of thejoint. Mr. Fergusson now proposed excision of all the bonesof the articulation which would be found in a diseased state,promising the patient not to remove the hand.The operation was performed on August 16, 1851, the patient

being under the influence of chloroform. Mr. Fergusson begunwith a longitudinal incision on the ulnar side of the wrist;a parallel incision was made on the radial side, and a transverseone about one inch above the wrist. All the carpal bones weresuccessively removed except the trapezium, the bases of threemetacarpal bones being likewise in a carious state, were alsotaken off, as well as the styloid process of the ulna. Novessels required ligatures. The operation was, from its nature,and Mr. Fergusson’s anxiety to keep the extensor tendons frominjury, extremely tedious, and the patient a long time re-

covering from chloroform. The arm was placed on a splintsimilar to that used before the operation. ’The greatest care was taken in the dressing of the wound,

but the suppuration proved very profuse, cicatrization did notadvance as steadily as could be wished, and several monthspassed away before any satisfactory progress was made. Itseemed as if the part had not sufficient power to assume ahealthy action, nor was it at all unlikely that the patient’sconstitution had a large share in this unfavourable result. Itcould hardly escape the attention of the observer, when view-ing the hands lying on the resting-board, and connected withthe lower end of the forearm only by some skin and a fewtendons, that it would require an active and healthy circula-tion in the part to counteract the tendency to purulent trans-formation, and excite that amount of fibrinous deposit andorganization which might have taken the place of the absentcarpal bones. Nor should it be forgotten that one principalelement of the process of cicatrization is generally absent inthese cases-viz., perfect apposition of the supposed healthyosseous surfaces. To effect this, it is plain that pressureshould not be applied in the usual circular way, but so con-trived as to produce its effects from before backwards, thusbringing the heads or shafts of the metacarpal bones in almostactual contact with the lower ends of the radius and ulna.Nor is it to be feared that the apposition will become too exact,and be followed by osseous anchylosis; some space will, fromthe very structure of the parts, always be left for the formationof an artificial joint. This patient, after remaining almostnine months in the hospital, was finally discharged on the26th of April, 1852, that he-might reap the benefit of countryair. It was expected that he would eventually show himselfat the hospital, so as to give Mr. Fergusson an opportunity ofascertaining what progress he had made; for, on leaving thehospital, the various ulcerated openings and wounds made bythe knife were not cicatrized and discharging much pus. Itis very probable that, if any further operation had been re-quired, amputation would have had the preference. We nowturn to a third case of excision of the wrist-joint, (includingMr. Erichsen’s, published in the last "Mirror,") also performedby Mr. Fergusson.

Caries of the Wrist-joint; Excision of the Carpal Bones.

(Under the care of Mr. FERGUSSON.)

George M-, aged twenty-eight years, and a watchmakerby trade, was admitted May 4, 1853. There is no history ofsyphilis; the patient has one brother now consumptive, butthe rest of the family are healthy. Three years before admis-sion a swelling came over the head of the metatarsal bone ofthe little finger; in about three months this was opened, andcontinued for some time to discharge a great quantity of pus,the swelling still increasing and extending to the wrist. Aboutnine months before the patient was seen here the finger wasamputated, and the metacarpal bone removed. About a monthafter this operation the patient went to St. Bartholomew’sHospital, the swelling still increasing in the wrist; iodine wasapplied externally, and cod-liver oil and iodide of potassiumgiven internally. Three weeks before admission here a punc-ture was made on the radial side of the wrist, and a poulticeapplied.

State on admission. -There is much swelling in the joint;the wound left after the amputation of the finger and thatmade last for letting out matter are not healed. There is aconsiderable degree of pain about the part, and the puffinessso characteristic of diseased joints. The patient’s health is

pretty good, and his constitution, though originally somewhatstrumous, does not offer any very-striking features of scrofula.On May 21st, Mr. Fergusson, having ascertained the exist-

ence of disease in the wrist, proceeded to operate, and removedmost of the carpal bones, and also gouged out a small portionof the extremity of the radius. Mr. Fergusson took advantageof the openings already existing, in order to take hold of thedifferent carpal bones, being at the same time careful not toinjure any of the flexors or extensors. The operation was of anextremely laborious character, as it was a matter of some diffi-culty to seize upon the bones, and remove them without in-juring the tendons, and without considerably enlarging theopenings. Mr. Fergusson succeeded, however, in taking awaythe greater portion of the carpal bones. The wrist and lowerpart of the forearm were wrapped in wet lint, and the patientsent to bed.

Fifth day after the operation.— Wound healing by granula-tion ; to have cod-liver oil. The wound progressed veryfavourably until June 10th, twenty days after the operation.

100

when a rash appeared at the back of the hand, and the wristswelled again, the discharge being somewhat foetid. Mr.

Fergusson made a small puncture over the wrist-joint, whensome ill-smelling pus escaped. The appearance of the partwas thereby materially improved. The dressing, with gentlecompression, was continued.Two months after the operation another puncture was made,

when only blood was evacuated, and the patient progressedpretty satisfactorily for several weeks, as far as his generalhealth was concerned; but no signs of active cicatrizing effortwere noticed in the wrist, which lay on the splint, displayingthe different apertures which had been made, and which didnot show any disposition to heal. Some motion was retainedin the fingers to a very small extent, but enough to show thatthe flexors and extensors, as well as the extremities of thecorresponding muscles, had not sustained any damage.

Mr. Fergusson, fearing that possibly some carious bone hadbeen left, had the patient brought into the theatre on October7th, and narcotized with chloroform. Diseased bone in the

region of the wrist was removed in the same manner as hadbeen done before, and a portion of the end of the radiustaken away at the same time. The treatment was continuedas before, but on January 7th, eight months after the originalexcision, some more carious bone was removed; and when wesaw the wrist and hand a few days ago, the parts were in apretty favourable state. Several ulcerated apertures might beobserved both on the palmar and dorsal aspect of the hand;these were smaller than they had originally been, and Mr.Fergusson conceives that there is some likelihood of a finalcicatrization taking place, leaving to the patient a moderatelyuseful hand. Let us now turn to the case of excision of thewrist-joint performed by Mr. Simon.

ST. THOMAS’S HOSPITAL.

Disease of the Carpus ; Excision of the Wrist-joint.(Under the care of Mr. SIMON.)

JOHN LL-, aged nineteen years, rather thin, of fair hairand skin, and a porter by trade, was admitted, May 25, 1852,into Abraham’s ward. The patient’s parents and his brothersand sisters are healthy. In May, 1851, he went into St. Bar-tholomew’s Hospital for a swelling in the thigh, which turnedout to be an abscess ; this was opened, and a considerableamount of purulent matter was discharged. The boy remainedfive months in that institution, and left with the wound in thethigh not quite closed up. Whilst out of the hospital thebandage came off, and the above-mentioned wound bled pro-fusely. When the hæmorrhage had ceased it was replaced bya considerable discharge of purulent matter, and to such anextent that the patient applied to the surgery at St. Thomas’sHospital. After about six months’ attendance as an out-

patient, the boy gradually recovered his health, the wound inthe thigh eventually cicatrizing completely. But whilst matterswere proceeding so favourably, an abscess formed over themetacarpal bone of the left hand. This purulent collectionwas treated in the usual way; but the affection of the handbecame worse as the thigh was getting better ; and it wasfound advisable, on May 25, 1852, as stated above, to receivethe boy into the house, the accumulations of pus having ex-tended to the wrist-joint. The osseous affection of the latterjoint was treated by Mr. Simon for about two months on thegenerally received principles of surgery ; and at the end of thatperiod, he removed one of the metacarpal bones. The woundmade for that purpose had scarcely healed when fresh abscessesformed ; and Mr. Simon having ascertained, by probing thejoint, that most of the bones of the wrist were in a cariousstate, resolved to make an effort to save the hand and takeaway all the diseased bone of the articulation, with the hopethat when these causes of irritation had been removed healthyaction would be set up, and the boy would recover, with a par-tially anchylosed, but still somewhat useful wrist and hand. Itwill here be necessary, before mentioning the mode of operationadopted by Mr. Simon, to remind our readers that Mr. Erichsen(see last " Mirror") removed the bones of the wrist by lateralincisions, and Mr. Fergusson (see above), also, by lateral in-cisions in one case, and by enlarging the orifices of fistuloustracts in another case. Mr. Simon, in contemplating the sameexcision, thought that the diseased osseous texture might beadvantageously taken away by making two long incisions onthe anterior and posterior aspects of the joint, reaching fromabout two inches above the wrist, back and front, to thecentre of the palm and dorsum of the hand, the incisions beingso managed as to run between the tendons coursing down to

their destination on the metacarpal bones and fingers. On the9th of October, Mr. Simon proceeded to operate in the mannerjust mentioned, and took away all the bones of the wrist exceptthe pisiform and trapezius ; one of the metacarpal bones wasalso excised. The wound made in front was brought togetherby sutures, but none were applied to the solution of continuityon the dorsum of the hand. Merely two vessels had to be tied.When the suppurative stage had set in, the wounds lookedsomewhat large ; but after a few weeks’ careful dressing, con-traction began to take place. This patient progressed asfavourably as might be expected for the first few months ; butthe time came, as happens with many excisions of joints, whenreparative action ceases, several portions of the wound re-maining unclosed, and discharging a rather large quantity ofpus, whilst the boy was regaining, under the influence of gooddiet, cod-liver oil, tonics, &c. &c., a fair amount of health.One year thus passed away, and just when it might be hopedthat the final cicatrization of parts was not far distant, thepatient was seized with all the symptoms of continued fever,and died about thirteen months after admission. It is to beregretted that no post-mortem examination was made ; but itis clear, from the manner in which the patient was attacked,that he sunk under an affection independent of the operationabove detailed. One circumstance should, however, alwaysbe taken into account-viz., the protracted stay of patients inhospital; this is, in most cases, extremely prejudicial to generalhealth, and should always, as far as practicable, be avoided.It is very probable that many cases of partial or complete re-section would end more favourably if the patients were as soonas possible removed from the wards, and placed under themost favourable influences as regards general health. In fact,there is but little to do beyond simply dressing the wound aftera few weeks are elapsed, and we consider that attention to thissuggestion will tend to render the practice of excision of bonesand joints more popular, as the results will be obtained in ashorter time than is now the case. The three preceding casesare not encouraging, but we need hardly say that the numberis not sufficient to settle the question either way; we shall, inthe meanwhile, not allow any opportunity to escape of givingpublicity to the further trials which may be made in the samedirection. We now turn for an instant to the lower extremity,and desire to fix attention for a few moments on a modificationmade by Mr. Simon to Syme’s amputation at the ankle-joint.

Modification of Syme’s Operation at the Ankle-joint; Non-Excision of the A stragalus.

(Fnder the care of Mr. SiMON.)The question arising out of Mr. Simon’s operation is, whether

it is an advantage to leave the astragalus in the amputationat the ankle-joint, supposing that bone to have escaped theprocess of caries going on in the tarsus. It is alleged, onthe one side, that it is of importance to preserve articularmovements in the lower part of the leg, so as to increase theusefulness of the shoe, and allow of a kind of natural flexionand extension; whilst others contend that much of the steadi-ness and firmness afforded by the long lever of the tibia andfibula are lost by preserving the tibio-astragaloid articulation.We do not pretend to strike the scale; but it seems in somedegree a pity to take away a perfectly healthy bone, and itmay perhaps be maintained (though surgical machinists wouldbe most competent to decide the question) that some degree ofmovement between the tibia and the shoe might be of advan-tage. However this may be, we are bound to say that Mr.Simon has had a case of the kind in private practice, wherehis modification of Syme’s operation at the ankle answeredadmirably. We find that this first astragalar amputation wasperformed as far back as May, 1848; and we are inclined tothink that this case, with the one which was admitted into St.Thomas’s Hospital, are the only instances in which the opera-tion has been performed in this country. The patient wasabout iifteen years of age, and suifered from scrofulous cariesand necrosis, affecting the front and outside of the tarsus, ex-tending even to the os calcis, but sparing the astragalus. It ofcourse required care to verify this. The boy’s health wasbreaking down, and it was judged necessary to remove thesource of irritation; but as Mr. Simon had ascertained that theastragalus was not diseased, he resolved to leave that bone.The operation was performed in the same way as is generallyadopted for amputation at the ankle-joint, the knife runningbetween the astragalus and os calcis, instead of being workedbetween the astragalus and the lower extremity of the tibiaand fibula. The flap was taken in the same manner as in theordinary amputation at the ankle-joint, and the stump turned